Risk factors for short-term outcomes after thoracoscopic lobectomy for lung cancer

Factors associated with failure of cardiopulmonary function recovery after lung cancer surgery

BACKGROUND AND OBJECTIVE

This study aimed to evaluate the longitudinal changes in cardiopulmonary function (CPF) and identify predictors of cardiopulmonary recovery failure after lung cancer surgery.

METHODS

Data was obtained from a prospective CATCH-LUNG cohort study, where patients were divided into two groups based on 6-min walk distance (6MWD) at baseline and 6 months after surgery. CPF recovery failure was defined as a participant whose 6MWD dropped over 50 m from baseline to 6 months after surgery. Patients with a baseline 6MWD less than 400 m were excluded. The analysis was investigated using mixed effects models, and the relative estimates for the predictors were expressed relative risk (RR) and 95% CI using a Poisson regression.

RESULTS

Among 419 patients, 24.1% and 17.7% showed failure of CPF recovery at 6 months and 1 year after surgery, respectively. In the multivariable analysis, baseline step count [RR per 1000 steps lower = 1.05 (95% CI, 1.01-1.09)], baseline dyspnoea [RR per 10 points higher = 1.15(1.07-1.23)], decreased FEV1 % predicted from baseline to 2 weeks after surgery [RR per 10% lower = 1.30(1.10-1.53)] and decreased moderate-to-vigorous physical activity (MVPA) from baseline to 2 weeks [RR = 1.95(1.22, 3.11)] or persistent low MVPA at baseline and 2 weeks after surgery [RR = 1.63(1.04, 2.54)] were significant factors for loss of CPF.

CONCLUSION

The inability to recover CPF at 6 months after surgery was linked to reduction of lung function and MVPA from baseline to 2 weeks as well as baseline physical activity (PA) and dyspnoea. These results imply that engagement of perioperative PA is necessary to facilitate recovery of CPF after lung cancer surgery.

Survival prediction for stage I-IIIA non-small cell lung cancer using deep learning

BACKGROUND AND PURPOSE

The aim of this study was to develop and evaluate a prediction model for 2-year overall survival (OS) in stage I-IIIA non-small cell lung cancer (NSCLC) patients who received definitive radiotherapy by considering clinical variables and image features from pre-treatment CT-scans.

MATERIALS AND METHODS

NSCLC patients who received stereotactic radiotherapy were prospectively collected at the UMCG and split into a training and a hold out test set including 189 and 81 patients, respectively. External validation was performed on 228 NSCLC patients who were treated with radiation or concurrent chemoradiation at the Maastro clinic (Lung1 dataset). A hybrid model that integrated both image and clinical features was implemented using deep learning. Image features were learned from cubic patches containing lung tumours extracted from pre-treatment CT scans. Relevant clinical variables were selected by univariable and multivariable analyses.

RESULTS

Multivariable analysis showed that age and clinical stage were significant prognostic clinical factors for 2-year OS. Using these two clinical variables in combination with image features from pre-treatment CT scans, the hybrid model achieved a median AUC of 0.76 [95 % CI: 0.65-0.86] and 0.64 [95 % CI: 0.58-0.70] on the complete UMCG and Maastro test sets, respectively. The Kaplan-Meier survival curves showed significant separation between low and high mortality risk groups on these two test sets (log-rank test: p-value < 0.001, p-value = 0.012, respectively) CONCLUSION: We demonstrated that a hybrid model could achieve reasonable performance by utilizing both clinical and image features for 2-year OS prediction. Such a model has the potential to identify patients with high mortality risk and guide clinical decision making.

Prediabetes in Syria and Its Associated Factors: A Single-Center Cross-Sectional Study

INTRODUCTION

Prediabetes is a major risk factor for diabetes and many chronic complications, particularly cardiovascular disease (CVD). Risk factors vary among races and demographics. This is the first study to assess prediabetes in Syria and its relevant risk factors.

METHODS

This cross-sectional study was conducted in a primary health clinic in Al-Mouwasat University Hospital, the major Hospital in Damascus, Syria. Interviews, examinations, and blood investigations were carried out by qualified physicians in the clinic.

RESULTS

This study included 406 participants, of which 363 (89.4%) were females, 43(10.6%) were males, 91 (22.4%) had prediabetes, 108 (26.6%) were overweight, and 231 (56.9%) were obese. Older age, positive family history of diabetes, obesity, abdominal obesity in females, high cholesterol, being married, and CVD were statistically significantly associated with prediabetes (p < 0.05). However, prediabetes was not associated with gender, living in the city or country, cigarette smoking, hypertension, diet, triglycerides, or polycystic ovary syndrome (p > 0.05). However, in the multivariable analysis, only high cholesterol, familial diabetes, and waist diameter had significant association.

CONCLUSIONS

Prevalence of prediabetes in our study in Syria was higher than what was estimated by previous studies. While many risk factors were similar to other countries in the regions, other risk factors differed. These results were highly reflective of high burden of prediabetes and diabetes, mainly in relatively young females. Further studies are required to tackle this rising issue as it imposes major complications in the long term, and the high financial burden on the health care system.

Non-Fatal Occupational Injury Prevalence and Associated Factors in an Integrated Large-Scale Textile Industry in Addis Ababa, Ethiopia

Occupational injuries disproportionately impact workers of the textile industry in low-income countries. The present study investigates the prevalence of non-occupational injury and its associated factors among workers in an integrated textile industry in Addis Ababa, Ethiopia. A cross-sectional study was conducted from 17–26 May 2021. A total of 311 workers were eligible for participation. The information was collected through an interview-administered questionnaire. The findings were presented with descriptive statistics and the relationship among variables was assessed with multi-variable analyses. A total of 291 (93.6%) participants were interviewed. The prevalence of non-fatal occupational injury was 11% [95% CI: 7.7–15.5] in the past 12 months. The hands and fingers were the most affected body parts. Male gender [AOR: 3.40; 95% CI (1.13–10.5)], the age group of 18–29 years [AOR: 6.69; 95% CI (1.35–32.7)], sleeping less than seven hours in a night [AOR: 2.67; 95% CI (1.03–6.97)], machine-based jobs [AOR: 3.59; 95% CI (1.02–12.6)], the workplace housekeeping [AOR: 5.87; 95% CI (1.45–23.8)], and inadequate empowerment to prevent injury accident [AOR: 4.6; 95% CI (1.01–20.9)] were associated factors with occupational injury. The prevalence of non-fatal occupational injuries is lower than the previous studies among textile workers. As a result, improving workplace safety, changing sleeping habits, and empowering workers to participate in injury prevention should be a priority in intervention.

Pre-operative Physical Performance Is Associated With Early Return to Work in Peri-operative Lung Cancer Patients

Little is known about the factors related to return to work (RTW) in patients with peri-operative lung cancer (LC). This study aimed to investigate whether pre-operative physical performance is associated with early RTW in patients with peri-operative LC. A total of 59 patients who wished to resume work after lung resection surgery were included and were divided into three groups: early RTW (within 14 days after discharge), delayed RTW (within 15-90 days), and non-RTW (failure of RTW within 90 days). The early RTW group had significantly lower scores on the modified Medical Research Council dyspnea scale (mMRC) and significantly higher scores on the Euro Quality of Life 5-Dimension 3-Level (EQ-5D-3L) than the non-RTW group. Multivariate logistic regression analysis showed that EQ-5D-3L scores were significantly associated with early RTW, and mMRC scores and knee extensor strength tended to be associated with early RTW. Better pre-operative quality of life, mild dyspnea, and greater lower limb muscle strength tended to be associated with early RTW in patients with peri-operative LC.

Impact of COVID-19 on residency choice: A survey of New York City medical students

Objectives

The Coronavirus disease 2019 (COVID-19) pandemic disrupted medical student education, particularly in New York City (NYC). We aimed to assess the impact of the COVID-19 pandemic on medical students’ residency choices.

Methods

The authors conducted a cross-sectional survey of medical students in all years of study at four NYC medical schools (Columbia, Cornell, NYU, and SUNY Downstate). The survey was fielded from 19 Aug 2020 to 21 Sep 2020. Survey questions included items assessing COVID-19 impact on residency choices, personal impact of COVID-19, residency/specialty choices, and factors influencing these choices.

Results

A total of 2310 students received the survey, with 547 (23.7%) providing partial responses and 212 (9.2%) providing valid responses for our primary analysis. 59.0% of participants thought that COVID-19 influenced their choice of residency/specialty, with 0.9% saying the influence was to a great extent, 22.2% to some extent, and 35.8% very little. On multivariable analysis, factors that were independently associated with COVID-19 impacting residency choice included low debt ($1 to $99,999: _adjOR 2.23, 95%CI 1.02–5.03) compared with no debt and Other race/ethnicity (_adjOR 0.26, 95%CI 0.10–0.63) compared with White race/ethnicity. On secondary analysis of all participants answering survey items for logistic regression regardless of survey completion, direct personal impact of COVID-19 was significantly associated with COVID-19 impacting specialty choice (_adjOR 1.90, 95%CI 1.04–3.52). Moreover, 24 students (11.6%) reported a change in their top residency choice from before to during/after COVID-19, citing concerns about frontline work, work-life balance, and risk of harm.

Conclusions

Our study found that 3 in 5 (59.0%) participants felt that COVID-19 impacted their residency choice, with 11.6% of respondents explicitly changing their top specialty choice. Investigating the impact of the pandemic on medical student residency considerations is crucial to understand how medical career outlooks may change in the future.

Smoking habits and the influence of war on cigarette and shisha smoking in Syria

Tobacco smoking might be impacted by various influences, including psychological, socio-cultural, and economic factors. A community-based cross-sectional survey was conducted in Syrian Arab Republic from March to April 2019 using a web-based questionnaire. The survey aimed at assessing tobacco use (shisha and cigarettes) as well as examining the association between current tobacco use and various sociodemographic and war-related factors. The sample comprised 978 participants (251 males: 727 females) and had a mean age of 24.7 years (SD: 7.60). Most participants were single (n = 825, 84.4%), reside in Damascus and Rif-Dimashq (n = 579, 59.2%), and had a college/university education (n = 911, 93.1%). Concerning smoking, a total of 371 participants (37.9%) were identified to be current tobacco smokers, of whom 211, 84, 76 were exclusive shisha smokers, exclusive cigarette smokers, and dual smokers, respectively. The prevalence of cigarette smoking (exclusive and dual) among males and females was found to be 34.7%, and 10.0%, respectively. On the other hand, the prevalence of shisha smoking (exclusive and dual) among males and females was around 34.3% and 27.6%, respectively. Additionally, various factors have predicted a higher likelihood of cigarette smoking including male gender (AOR = 4.152; 95% CI: 2.842-6.064; p<0.001), and losing someone due to the war (AOR = 1.487; 95% CI: 1.028-2.151; p = 0.035), while unemployed individuals were found to have lower odds of being cigarette smokers (AOR = 0.634; 95% CI: 0.429-0.937; p = 0.022). Concerning shisha smoking, married (AOR = 0.622; 95% CI: 0.402-0.963; p = 0.033), and unemployed individuals (AOR = 0.679; 95% CI: 0.503-0.916; p = 0.011) were found to have lower odds of shisha smoking. Amid the tobacco epidemic in the region, rates of tobacco use in Syria are still worrying. The Syrian armed conflicts may possess a double-edged effect on smoking, and tobacco users who adopt smoking to cope with various stressors should be targeted with well-structured health education, along with appropriate psychological services.

Workplace stress and associated factors among vehicle repair workers in Hawassa City, Southern Ethiopia

INTRODUCTION

Workplace stress is a public health problem worldwide. Studies focusing on work-related stress among vehicle repair workers are scarce in African countries. The current study aimed to determine the prevalence of self-reported workplace stress and associated factors among vehicle repair workers in Hawassa City, South Ethiopia.

METHODS AND FINDINGS

A cross-sectional study design was employed among 347 vehicle repair workers from January 25 to February 22, 2019. Questionnaires were administered using interviews. Additional tools were used for weight and height measurements. The main findings were analyzed using descriptive statistics, bivariable, and multivariable logistic regression. The strength of association of variables was presented by odds ratio along with its 95% CI. The statistical assessments were considered significant at p<0.05. A total of 344 workers participated in the study. The prevalence of workplace stress among participants was 41.6% with 95% CI: (36.3-47.1). Factors associated with workplace stress were more than 10 years of work experience [AOR: 2.40; 95% CI (1.29-4.50)], work-related musculoskeletal disorder [AOR: 3.39; 95% CI (1.99-5.78)], squatting and lying work posture [AOR: 4.63; 95% CI (1.61-13.3)] and servicing large vehicles [AOR: 1.96; 95% CI (1.14-3.38)].

CONCLUSION AND RECOMMENDATIONS

This study showed that the overall prevalence of work-related stress was substantially high. The independently associated factors were workers' service years, symptoms of body pain, and the work environment. Preventive measures need to be implemented in vehicle repair workshops by focusing on work environment improvements.

Efficacy of preoperative white blood cell count and lymphocyte/monocyte ratio in predicting post-lobectomy pneumonia

Background

This study aims to examine preoperative white blood cell count and lymphocyte/monocyte ratio and to investigate foreknown risk factors for pneumonia following lobectomy.

Methods

Between January 2005 and May 2018, a total of 152 patients (135 males, 17 females; mean age: 61.9±7.5 years; range, 45 to 73 years) who underwent right lower lobectomy for non-small cell lung cancer were retrospectively analyzed. Data including age, sex, preoperative white blood cell count and lymphocyte/monocyte ratio, smoking, preexisting chronic diseases, body mass index, stage of lung cancer, the use of neoadjuvant chemotherapy, type of surgery, operation duration, blood transfusion, and postoperative intensive care unit admission were recorded.

Results

Twenty-five (16.4%) patients developed postoperative pneumonia. Older patients presenting with elevated levels of preoperative white blood cell count and lymphocyte/monocyte ratio, excessive tobacco consumption, prolonged operation duration, history of a chronic disease, a body mass index over 30 kg/m2, advanced lung cancer, neoadjuvant chemotherapy, and intensive care unit admission after surgery were at high risk for postoperative pneumonia. There was no significant difference in sex, type of surgery (thoracotomy versus thoracoscopy), and the use of blood products. In predicting the development of postoperative pneumonia, lymphocyte/monocyte ratio had 85.% sensitivity and 87.5% specificity, while white blood cell count had 72.5% sensitivity and 77.5% specificity.

Conclusion

Preoperative white blood cell count and lymphocyte/ monocyte ratio provide supporting evidence in predicting pneumonia following lobectomy contributing to the existing risk identification criteria.

Associations between pretreatment physical performance tests and treatment complications in patients with non-small cell lung cancer: A systematic review

This systematic review evaluated which outcome variables and cut-off values of pretreatment exercise tests are associated with treatment complications in patients with stage I-III non-small cell lung cancer (NSCLC). PRISMA and Cochrane guidelines were followed. A total of 38 studies with adult patients undergoing treatment for stage I-III NSCLC who completed pretreatment exercise tests, and of whom treatment-related complications were recorded were included. A lower oxygen uptake at peak exercise amongst several other variables on the cardiopulmonary exercise test and a lower performance on field tests, such as the incremental shuttle walk test, stair-climb test, and 6-minute walk test, were associated with a higher risk for postoperative complications and/or postoperative mortality. Cut-off values were reported in a limited number of studies and were inconsistent. Due to the variety in outcomes, further research is needed to evaluate which outcomes and cut-off values of physical exercise tests are most clinically relevant.

Association between Sarcopenia and Physical Function among Preoperative Lung Cancer Patients

We aimed to investigate the prevalence of sarcopenia using new diagnostic criteria and association of sarcopenia with cardiopulmonary function and physical activity (PA) in preoperative lung cancer patients. The data of 614 patients were obtained from the CATCH-LUNG cohort study. Patients were classified into three groups-normal (n = 520), pre-sarcopenia (n = 60, low skeletal muscle mass index only), and sarcopenia (n = 34, low SMI and strength). Cardiopulmonary function was measured using the 6-min walk test (6MWT), and PA was objectively measured using a wearable device. The adjusted odds ratio (aOR) for a <400-m distance in 6MWT was 3.52 (95% confidence interval (CI) 1.34-9.21) and 6.63 (95% CI 2.25-19.60) in the pre-sarcopenia and sarcopenia groups, respectively, compared to that in the normal group. The aOR (95% CI) for <5000 steps/day was 1.64 (0.65-4.16) and 4.20 (1.55-11.38) in the pre-sarcopenia and sarcopenia groups, respectively, compared to that in the normal group. In conclusion, the prevalence of pre-sarcopenia and sarcopenia was 9.8% and 5.5%, respectively, among preoperative lung cancer patients. Cardiopulmonary function and physical activity were significantly lower in the pre-sarcopenia and sarcopenia groups than in the normal group. Patients with sarcopenia had more robust findings, suggesting the importance of muscle strength and mass.

Short-Physical Performance Battery (SPPB) score is associated with postoperative pulmonary complications in elderly patients undergoing lung resection surgery: A prospective multicenter cohort study

Elderly patients awaiting lung resection surgery often have poor physical function, which puts them at a high risk of postoperative pulmonary complications. The aim of this study was to investigate the impact of preoperative physical performance on postoperative pulmonary complications in patients awaiting lung resection surgery. In this prospective multicenter cohort study, the characteristics of patients and postoperative pulmonary complications were compared between subjects with low (<10) and high (≥10) Short Physical Performance Battery (SPPB) scores. Postoperative pulmonary complications were defined as over grade II in Clavien-Dindo classification system. We estimated the effects of physical performance on postoperative pulmonary complications using multivariable hierarchical logistic regression. The postoperative pulmonary complications were compared between 331 patients in the high and 33 patients in the low SPPB group. Patients in the low SPPB score group had a significantly higher rate of postoperative pulmonary complications (p < 0.001). Low SPPB score was associated with a higher risk of postoperative pulmonary complications (odds ratio, 8.80; p < 0.001). The SPPB is a clinically useful evaluation tool to assess surgical patients’ physical performance. The low physical performance indicated by the SPPB may be predictive of postoperative pulmonary complications after lung resection surgery.

Trial registration: Clinical Trials. University hospital Medical Information Network Center (UMIN-CTR) UMIN000021875.

Knowledge, behaviour and attitudes towards Chagas disease among the Bolivian migrant population living in Japan: a cross-sectional study

OBJECTIVES

This study aimed to investigate the knowledge, behaviour and attitudes towards Chagas disease (CD) among Latin American migrants in Japan and to evaluate the effectiveness of an educational activity (EA) in increasing knowledge of CD.

DESIGN

A cross-sectional, mixed-methods study employing a preknowledge and postknowledge test and focus group discussion, conducted from March 2018 to June 2018.

PARTICIPANTS

Seventy-two participants were included, all born in Bolivia and residents in four Japanese cities. Fifty-nine of them participated in the EA.

INTERVENTIONS

The EA comprised showing three videos about CD and a group discussion covering different dimensions of CD and was evaluated with questionnaires to analyse the knowledge of the participants before and after.

RESULTS

Seventy-two participants were enrolled, predominantly from highly endemic CD areas of Bolivia. Though most participants were familiar with vector-borne transmission, epidemiology and symptomatology of CD, the baseline knowledge of CD was low. Less than 10% of them had been tested prior for CD. The dominant factors associated with better knowledge were living in Japan for more than 10 years (OR=8.42, 95% CI 1.56 to 48.62) and previously testing for CD (OR=11.32; 95% CI 1.52 to 105.9). The EA significantly improved the CD knowledge of the participants (p value <0.0001; 95% CI 2.32 to 3.84). The participants associated the term 'Chagas' mostly with fear and concern. The level of stigmatisation was low, in contrast to the results of other studies. The barriers encountered in care-seeking behaviour were language, the migration process and difficulties to access the healthcare system.

CONCLUSION

EA with an integrative approach is useful to increase the knowledge of CD within the Bolivian migrant population living in Japan. The activity brings the possibility to explore not only the level of knowledge but also to reveal experiences and to understand the needs of the people at risk. Considering them as actors towards healthcare solutions could lead to better outcomes for the success of future policies and interventions aimed to decrease the global burden.

Evaluation of alterations in serum immunoglobulin concentrations in components of metabolic syndrome, obesity, diabetes, and dyslipidemia

Purpose

Serum immunoglobulins (Igs) play a critical role in modulating the immune response by neutralizing pathogens, although little is known about the effect of Igs in development of atherosclerotic cardiovascular disease (ASCVD). Elevated serum Immunoglobulin A (IgA) concentrations have been identified in previous studies in populations with obesity and hypertriglyceridemia, whereas variable concentrations of Immunoglobulin M (IgM) have been observed in the setting of dyslipidemia.

Methods

In this cross-sectional study, investigators examined the association of serum Ig concentrations with components of metabolic syndrome, including obesity, diabetes, and dyslipidemia. All consecutive adult patients aged 18 years or older discharged from two academic teaching hospitals with serum Immunoglobulin G (IgG) concentration measured during their admission were evaluated, with a total of 1809 individuals included and stratified into two groups: those with and those without dyslipidemia.

Results

Mean IgG concentration in individuals with and without dyslipidemia was 997 ± 485 mg/dL and 1144 ± 677 mg/dL, respectively (P <  0.0001). After controlling for confounders in the generalized linear model (GLM), the least square mean IgG concentration in individuals with and without dyslipidemia was 1095 and 1239 mg/dL, respectively (P <  0.0001). The mean IgA and IgM concentrations were not significantly different in individuals with and without dyslipidemia both before and after adjusting covariates. After controlling for confounding variables, all three serum Ig concentrations were not significantly different in individuals with and without diabetes.

Conclusion

Dyslipidemia was associated with a lower mean serum IgG concentration. No association with any serum Ig was indentified in individuals with diabetes. Exploration of the association between alterations in serum Igs and metabolic syndrome and the role of alterations of Ig concentrations in disease progression represents an important step in identification of appropriate targeted treatment options for reducing cardiovascular risk.

A New Preprocedural Score to Predict Bleeding Complications of Endovascular Interventions for Peripheral Artery Disease

Purpose: To investigate the bleeding complications associated with endovascular therapy (EVT) for peripheral artery disease (PAD) and develop a dedicated peripheral bleeding score (PBS). Materials and Methods: This prospective, single-center study enrolled 530 patients (mean age 67.6±9.8 years; 396 men) undergoing endovascular procedures between August 2016 and July 2018 for chronic PAD. Primary endpoints were the incidence of 30-day bleeding complications [minor and major (prolonging hospitalization, causing permanent sequelae, or resulting in death)], the identification of factors associated with bleeding events, and the development of a dedicated PBS based on univariate and multivariate analysis. Hazard ratios (HR) and 95% confidence intervals (CI) are reported. The HAS-BLED score was compared with the PBS. Results: The overall peripheral bleeding complication rate was 3.8% (20/530), of which 3.2% (17/530) were major and included 4 (0.7%) active retroperitoneal bleeding events and 13 (2.4%) pseudoaneurysms. The annualized incidences of overall bleeding and major bleeding complications were 1.9% and 1.6%, respectively. Multivariable regression analysis identified age ≥75 as a correlate of significantly increased bleeding risk (HR 3.32, 95% CI 1.12 to 9.80, p<0.02). Male gender (HR 0.193, 95% CI 0.49 to 0.75, p<0.001) and statin therapy (HR 0.245, 95% CI 0.08 to 0.71, p=0.01) were correlated with a significantly decreased bleeding risk. Based on the regression analysis findings an 8-point PBS was developed, demonstrating 75.0% sensitivity and 78.4% specificity in detecting bleeding complications. The HAS-BLED score failed to identify 30-day bleeding events. Conclusion: The annualized incidence of bleeding complications associated with peripheral EVT was low. Advanced age and female sex were correlated with increased bleeding risk. The PBS demonstrated satisfactory statistical performance and could be considered for inclusion in the preprocedural endovascular checklist to help optimize intra- and postprocedural care.

Pathological lymph node involvement is not a predictor of adverse outcomes in patients undergoing thoracoscopic lobectomy for lung cancer†

OBJECTIVES

As the practice of video-assisted thoracoscopic surgery (VATS) lobectomy gains widespread acceptance, the complexity of procedures attempted increases and the stage of tumour that may be safely approached remains controversial. We examined the impact of nodal involvement with respect to perioperative outcomes after VATS lobectomy.

METHODS

All patients listed for VATS lobectomy for non-small-cell lung cancer at our institution from 2012 to 2016 were analysed. Bronchoplastic or chest wall resections and tumours over 7 cm were considered a contraindication to a thoracoscopic approach.

RESULTS

Of the 489 patients identified, 97 (19.8%) patients had pathological nodal involvement. The overall conversion rate was 6.1%, reoperation rate was 5.3% and readmission rate was 5.9%. Median hospital stay was 5 days, 30-day mortality was 0.6% and 90-day mortality was 1.6%. No significant difference was identified between the nodal-negative or -positive groups in terms of preoperative demographics, hospital stay, postoperative complications, conversion rate, reoperation rate or readmission rate. Univariate logistic regression identified gender, Thoracoscore, dyspnoea score, performance status, chronic obstructive pulmonary disease, previous stroke, preoperative lung function and non-adenocarcinoma as predictors of postoperative complications. A multivariate model including nodal status identified Thoracoscore (odds ratio 1.57, 95% confidence interval 1.16-2.18; P < 0.001) and preoperative transfer factor (odds ratio 0.97, 95% confidence interval 0.96-0.98; P < 0.001) as the only predictors of complications.

CONCLUSIONS

In non-small-cell lung cancer patients with pathological hilar or mediastinal lymph node involvement, VATS lobectomy can be safely performed, as there does not appear to be an adverse effect on the incidence of perioperative complications, length of stay or readmissions.

Comparative Effectiveness of Robotic-Assisted Surgery for Resectable Lung Cancer in Older Patients

BACKGROUND

Robotic-assisted surgery (RAS) is a novel surgical approach increasingly used for patients with non-small cell lung cancer (NSCLC). However, data comparing the effectiveness and costs of RAS vs open thoracotomy and video-assisted thoracoscopic surgery (VATS) for NSCLC are limited.

METHODS

Patients > 65 years old with stage I to IIIA NSCLC treated with RAS, VATS, or open thoracotomy were identified from the Surveillance, Epidemiology, and End Results-Medicare database and matched according to age, sex, stage, and extent of resection. Propensity score methods were used to compare adjusted rates of postoperative complications, adequate lymph node staging, survival, and treatment-related costs.

RESULTS

In this matched study cohort of 2,766 patients with resected NSCLC, RAS was associated with lower complication rates (OR, 0.57; 95% CI, 0.42-0.79) compared with open thoracotomy, and similar complication rates (OR, 1.02; 95% CI, 0.76-1.37) compared with VATS. Patients undergoing RAS were as likely to have adequate lymph node sampling as those undergoing open thoracotomy (OR, 1.28; 95% CI, 0.94-1.74) or VATS (OR, 0.88; 95% CI, 0.66-1.18). There was no significant difference in overall survival after RAS vs open thoracotomy (hazard ratio, 0.81; 95% CI, 0.63-1.04) or VATS (hazard ratio, 0.91; 95% CI, 0.70-1.18). Costs were similar for RAS ($54,702) vs open thoracotomy ($57,104; P = .08), and higher compared with VATS ($48,729; P = .02).

CONCLUSIONS

RAS led to improved operative outcomes compared with open thoracotomy but may not offer an advantage over VATS. The comparative effectiveness of RAS should be further evaluated prior to widespread adoption.

Chronic Obstructive Pulmonary Disease and Lung Cancer: Underlying Pathophysiology and New Therapeutic Modalities

Chronic obstructive pulmonary disease (COPD) and lung cancer are major lung diseases affecting millions worldwide. Both diseases have links to cigarette smoking and exert a considerable societal burden. People suffering from COPD are at higher risk of developing lung cancer than those without, and are more susceptible to poor outcomes after diagnosis and treatment. Lung cancer and COPD are closely associated, possibly sharing common traits such as an underlying genetic predisposition, epithelial and endothelial cell plasticity, dysfunctional inflammatory mechanisms including the deposition of excessive extracellular matrix, angiogenesis, susceptibility to DNA damage and cellular mutagenesis. In fact, COPD could be the driving factor for lung cancer, providing a conducive environment that propagates its evolution. In the early stages of smoking, body defences provide a combative immune/oxidative response and DNA repair mechanisms are likely to subdue these changes to a certain extent; however, in patients with COPD with lung cancer the consequences could be devastating, potentially contributing to slower postoperative recovery after lung resection and increased resistance to radiotherapy and chemotherapy. Vital to the development of new-targeted therapies is an in-depth understanding of various molecular mechanisms that are associated with both pathologies. In this comprehensive review, we provide a detailed overview of possible underlying factors that link COPD and lung cancer, and current therapeutic advances from both human and preclinical animal models that can effectively mitigate this unholy relationship.

Routine intensive monitoring but not routine intensive care unit-based management is necessary in video-assisted thoracoscopic surgery lobectomy for lung cancer

Background

Evidence for immediate postoperative intensive care unit (ICU) care is still lacking in the era of minimally invasive video-assisted thoracic surgery (VATS). We evaluated the safety and feasibility of general ward (GW) care after VATS lobectomy for lung cancer.

Methods

A total of 451 patients who underwent VATS lobectomy for lung cancer between June 2012 and August 2017 were retrospectively studied. The patients were divided into two groups (ICU 344 vs. GW 107). We compared the postoperative complications and mortality between the two groups after propensity score matching. Furthermore, we evaluated the clinical factors associated with complications, and stratified patients according to the risk for complications.

Results

Immediate complications (within 24 hours after surgery) occurred in 0.4%. Non-immediate complications occurred in 18.8%. There were no differences in the incidence of complications and mortality between the two groups, after propensity matching. However, the length of postoperative stay (12.6±10.0 vs. 10.3±4.1 days, P=0.041) was significantly higher in the ICU group than in the GW group. Multivariate regression analyses revealed that chronic obstructive pulmonary disease (COPD) [odds ratio (OR) =3.00, 95% confidence interval (CI): 1.51-5.97, P=0.002], non-stage I cancer (OR =2.54, 95% CI: 1.39-4.62, P=0.002), multi-port surgery (OR =3.75, 95% CI: 2.18-6.44, P<0.001), and age ≥60 years (OR =2.12, 95% CI: 1.03-4.37, P=0.042) were associated with complications. Immediate postoperative care in GW had no influence on complications.

Conclusions

Immediate postoperative care after VATS lobectomy for lung cancer in GW was safe and feasible without poor outcomes. Therefore, selective intensive monitoring for high risk groups may offer cost-saving and efficient use of ICU resources.

Improved long-term survival following pulmonary resections for non-small cell lung cancer: results of a nationwide study from Iceland

Background

We studied the outcome of pulmonary resection with curative intent for non-small cell lung cancer (NSCLC) in a nationwide study covering a 24-year period, focusing on survival.

Methods

All patients who underwent pulmonary resection for NSCLC in Iceland in the period 1991-2014 were reviewed for demographics, TNM stage and survival. Median length of follow-up was 45 months. Three 8-year periods were compared, overall survival was estimated, and prognostic factors for survival were identified.

Results

Altogether, 652 surgical resections were performed on 644 individuals (52% females): 492 lobectomies (75%), 77 pneumonectomies (12%), and 83 sublobar resections (13%). Mean age increased from 65 to 68 yrs during the study period (P=0.002). The number of cases operated at stage IA increased substantially between the first and last periods (29% vs. 37%; P<0.001). Survival improved from 75% to 88% at 1 year and from 38% to 53% at 5 years (P<0.001). Independent prognostic factors for mortality were advanced TNM stage (HR =2.68 for stage IIIA vs. I), age (HR =1.04), ischaemic heart disease (HR =1.26), any minor complication (HR =1.26), and sublobar resection (HR =1.33), but surgical margins free from tumour growth (HR =0.59) and treatment during the latter two eight-year periods were predictors of lower mortality. The best survival was seen between 2007 and 2014 (HR =0.61, 95% CI: 0.48-0.78; P<0.001).

Conclusions

Survival of patients who have undergone pulmonary resection for NSCLC has improved significantly in Iceland. This may be explained by the increased number of patients diagnosed at lower stages and improved preoperative staging, with fewer understaged patients.

[Effect of A High Intensive Preoperative Rehabilitation on the Perioperative Complications in Patients with Chronic Obstructive Pulmonary Disease Eligible for Lung Cancer Surgery]

背景与目的

慢性阻塞性肺病(chronic obstructive pulmonary diseases, COPD)降低患者心肺功能，可导致患者围手术期风险增加。本研究拟探讨术前短期高强度肺康复训练对肺癌合并COPD患者肺功能及术后并发症的影响。

方法

分析2016年6月-2016年12月101例肺癌合并COPD患者的临床资料，其中肺康复训练组43例，常规治疗组58例，比较两组患者肺功能、术后肺部并发症、住院时间等指标，同时比较肺康复训练组训练前后肺功能相关指标。

结果

两组患者术前一般资料及肺功能无显著差异，康复训练组住院时间更长[(17.23±4.18) d vs (14.41±4.03) d]，但术后住院时间与常规治疗组无显著差异[(8.93±3.78) d vs (9.62±3.98) d]，两组患者术后肺部感染[8例(18.6%) vs 17例(29.3%)]、肺不张[1例(2.3%) vs 1例(1.7%)]、呼吸衰竭[1例(2.3%) vs 2例(3.4%)]等无显著差异。肺康复训练组训练前后FEV₁[(2.06±0.45) L vs (2.15±0.45) L, P < 0.001]、PEF[(4.32±0.90) L/s vs (5.15±1.05) L/s, P < 0.001]、PCO₂[(42.42±2.79) mmHg vs (41.58±2.98) mmHg, P=0.009]改善明显，按亚组分析，康复训练后中-重度COPD亚组FEV₁[(0.16±0.05) L (8.6%) vs (0.06±0.05) L (2.8%)]增加值较轻度COPD亚组更明显。

结论

术前短期肺康复训练可改善肺癌合并COPD患者肺功能，其中中-重度COPD患者肺功能改善更明显。

Lobectomy for non-small cell lung carcinoma: a nationwide study of short- and long-term survival

INTRODUCTION

Lobectomy is the standard curative treatment for non-small cell carcinoma (NSCLC) of the lung. Most studies on lobectomy have focused on short-term outcome and 30-day mortality. The aim of this study was to determine both short-term and long-term surgical outcome in all patients who underwent lobectomy for NSCLC in Iceland over a 24-year period.

MATERIAL AND METHODS

The study involved 489 consecutive patients with NSCLC who underwent lobectomy with curative intent in Iceland, 1991-2014. Patient demographics, pTNM stage, rate of perioperative complications, and 30-day mortality were registered. Overall survival was analyzed with the Kaplan?Meier method. The Cox proportional hazards model was used to evaluate factors that were prognostic of overall mortality. To study trends in survival, the study period was divided into six 4-year periods. The median follow-up time was 42 months and no patients were lost to follow-up.

RESULTS

The average age of the patients was 67 years and 53.8% were female. The pTNM disease stage was IA in 148 patients (30.0%), IB in 125 patients (25.4%), IIA in 96 patients (19.5%), and IIB in 50 patients (10.1%), but 74 (15.0%) were found to be stage IIIA, most often diagnosed perioperatively. The total rate of major complications was 4.7%. Thirty-day mortality was 0.6% (three patients). One- and 5-year overall survival was 85.0% and 49.2%, respectively, with 3-year survival improving from 48.3% to 72.8% between the periods 1991-1994 and 2011-2014 (p = .0004). Advanced TNM stage and age were independent negative prognostic factors for all-cause mortality, and later calendar year and free surgical margins were independent predictors of improved survival.

CONCLUSIONS

The short-term outcome of lobectomy for NSCLC in this population-based study was excellent, as reflected in the low 30-day mortality and low rate of major complications. The long-term survival was acceptable and the overall 3-year survival had improved significantly during the study period.

Association of Delayed Adjuvant Chemotherapy With Survival After Lung Cancer Surgery

IMPORTANCE

Adjuvant chemotherapy offers a survival benefit to a number of staging scenarios in non-small-cell lung cancer. Variable recovery from lung cancer surgery may delay a patient's ability to tolerate adjuvant chemotherapy, yet the urgency of chemotherapy initiation is unclear.

OBJECTIVE

To assess differences in survival according to the time interval between non-small-cell lung cancer resection and the initiation of postoperative chemotherapy to determine the association between adjuvant treatment timing and efficacy.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective observational study examined treatment-naive patients with completely resected non-small-cell lung cancer who received postoperative multiagent chemotherapy between 18 and 127 days after resection between January 2004 and December 2012. The study population was limited to patients with lymph node metastases, tumors 4 cm or larger, or local extension. Patients were identified from the National Cancer Database, a hospital-based tumor registry that captures more than 70% of incident lung cancer cases in the United States. The association between time to initiation of adjuvant chemotherapy and survival was evaluated using Cox models with restricted cubic splines.

EXPOSURES

Adjuvant chemotherapy administered at different time points after surgery.

MAIN OUTCOMES AND MEASURES

Effectiveness of adjuvant chemotherapy according to time to initiation after surgery.

RESULTS

A total of 12 473 patients (median [interquartile range] age, 64 [57-70] years) were identified: 3073 patients (25%) with stage I disease; 5981 patients (48%), stage II; and 3419 patients (27%), stage III. A Cox model with restricted cubic splines identified the lowest mortality risk when chemotherapy was started 50 days postoperatively (95% CI, 39-56 days). Initiation of chemotherapy after this interval (57-127 days; ie, the later cohort) did not increase mortality (hazard ratio [HR], 1.037; 95% CI, 0.972-1.105; P = .27). Furthermore, in a Cox model of 3976 propensity-matched pairs, patients who received chemotherapy during the later interval had a lower mortality risk than those treated with surgery only (HR, 0.664; 95% CI, 0.623-0.707; P < .001).

CONCLUSIONS AND RELEVANCE

In the National Cancer Database, adjuvant chemotherapy remained efficacious when started 7 to 18 weeks after non-small-cell lung cancer resection. Patients who recover slowly from non-small-cell lung cancer surgery may still benefit from delayed adjuvant chemotherapy started up to 4 months after surgery.